Key Safety of Flight Issues in Aviation Maintenance Joseph Barclay Vice Chairman - MAC Flight Safety Foundation

The Maintenance Advisory Committee MAC established as a global think tank to identify key issues in aviation maintenance that have a negative effect on safety of flight Mission: “Increased commitment to the advancement of safety culture in the aviation maintenance community.” The MAC is a global think tank comprised of experts in maintenance safety from all over the world. The first meeting was held in February of 2013 in the FSF HQ outside of Washington DC. There are obviously many excellent organizations who have done very good work. The intent is not to duplicate work, but to understand why some excellent guidance is not consistently evident on the front lines in the maintenance environment.

The Impact to Flight Safety The Maintenance Role in Safety of Flight The Need for Comprehensive Review of Maintenance Issues Affecting Flight Safety Why is FSF involved in flight safety? Should we not concentrate on stick and rudder issues? Safety of flight begins on the ground with Maintenance and engineering processes, aircraft servicing and loading, etc. Flight safety is the product of sound quality and safety systems, it is not limited to procedures in the cockpit or air traffic centers. Because there are less accidents we cannot assume that there is less risk in aviation maintenance and engineering processes

Flight Safety Foundation in Maintenance FSF has long history in Maintenance and Engineering Aviation Mechanics Bulletins became a standard in shops and hangars all over the world Bulletins were incorporated into AeroSafety World in 2006 Later, after the foundation was established, FSF produced Aviation Mechanics Bulletins. These became popular all over the world. They were incorporated into ASW in 2006.

Flight Safety Foundation in Maintenance The “Mechanic’s Creed” was originally written by Jerome Lederer in 1941 The creed appeared on the back cover of the first issues of Flight Safety Foundation's Aviation Mechanics Bulletin in 1953 and proved to be extremely popular Mechanics around the world, "from Tokyo to Frankfurt, from Canada to Puerto Rico," wrote to request copies to hang in their offices and shops I am often asked why is FSF involved in maintenance? In the early days of aviation there were many challenges maintaining aircraft. Jerry Lederer wrote the Mechanic’s Creed back in 1941, even before establishing the Foundation.

Then and Now “Secondary causes were a generally low standard of maintenance due to lack of tools, spares, adequate lighting, hurried workmanship, and inexperience in lower staff grades.” 1948, Pakistan Airways C-47A “The [maintenance provider] quality assurance inspector’s failure to detect the incorrect rigging of the elevator system…” 2003, Air Midwest, B-1900 "The progressive failure of both engines, due to the lack of compliance with proper maintenance standards.“ 1953, Miami Airlines, DC-3 “The uncontrollable pitch up was caused by sudden uncommanded downward movement of the Trimmable Horizontal Stabilizer leading edge. This was due to partial detachment of its 'actuator forward bearing support' fitting due non installation of required hi-lok fasteners. Poor aircraft maintenance practices at [MRO] contributed to the accident." 1998, Alliance Air, Dornier 228 I read a lot of accident reports. One thing that is clear is that when you read a report from 40 or 50 years ago it is apparent that aviation has advanced at a very rapid pace. The reports look very different today because of the advancements of cockpit procedures and technology, CRM, rtc. But, when it comes to maintenance issues it is often difficult to tell past from present. Can you tell which ones are from the 40s and 50’s and which ones are more recent? I think you will agree that the issues in these accidents could very well be the cause of an accident today. While accident rates are at an all time low, we must address the risks present in maintenance operations.

What Are The Maintenance Issues? MAC reviewed maintenance accident history 4 “High Level” issues identified Review of existing work on these key issues The MAC reviewed accident data and had extensive dialogue about what members felt were the key issues in aviation maintenance affecting safety of flight. While many issues were identified, 4 issues were given priority initially. The issues were either a factor in past accidents or a concern in today's environment. Understanding the existing issues and what has been dome to date is key in trying to assess if we have improved on these issues, and if not, why not?

Failure to Follow Procedures Work targeted at understanding WHY procedures are not followed Review of previous work and guidance: Has guidance been effective? Why? What can be done about it? When reviewing maintenance accidents, or accidents in which maintenance was a contributing factor, the failure to follow procedure stands out as a key problem. Understanding WHY procedures are not followed in the first place is a key aspect of understanding how we can change the behavior.

Professionalism in Aviation Maintenance Professionalism – Marks of our Profession Conduct Methods Character Ethical Responsibilities Standards -PAMA The industry has changed because the demographics are changing. Maintaining professionalism at a high level is becoming a challenge. Why? How can we positively affect Conduct or character on the job? How do we implement standards to ensure a professional environment? What IS a professional environment? These are all questions we must answer. We cannot assume professionalism, it must be shaped. But to shape professionalism we must equip our leaders with the knowledge that goes much deeper than maintenance matters. We have to impact behavior on the front lines.

Oversight and Quality Quality systems must be assessed against operational context Contract maintenance is the norm Have systems been adjusted adequately? Regulatory oversight SMS interface Quality interface Quality and SMS interface Predictive systems integration The quality systems must meet specific needs of the operator and ensure that standards are maintained. Contract maintenance is here to stay. Civil aviation agencies have had to adjust how they oversee an operation, as maintenance performed on an operator’s aircraft may be performed anywhere in the world, as long as the MRO has the proper credentials. How do regulatory agencies manage the work load in the face of mounting economic challenges? How do we ensure the same standards are used? Operators design their SMS with a comprehensive understanding of their operational context. The size and scope of these

Leadership and Safety Culture Leadership can shape professionals BUT HOW DO WE SHAPE LEADERSHIP? Safety Culture is a product of many things WHICH ONES CAN WE MANAGE? Maintenance is a different environment the flight operations. The people we value most have excellent technical skills. Good technicians will progress in most places. They normally achieve a position based on their technical skills, but then we ask them to perform in a role where their skills do not transfer. These front line managers affect the most important part of our operations, one that most of us do not even manage, or measure….our safety culture. It is obvious that one of the things that drives many of the issues in maintenance is the environment in which people work. It affects how we act, how we perceive compliance and how we act. Now think of the complexity of safety culture of your maintenance providers. If you contract maintenance, is the safety culture of an MRO something you should be looking at? How do you measure that?

The Way Forward The MAC is continuing to analyze issues and develop mitigation strategies Working groups being developed International perspective is important Solutions must be feasible to be effective Business minded approach Return on investment Realistic Front line impact Quality approach Measurable results

Leadership and Safety Culture Ed MacAskill - MAC Member Brad Brugger – MAC Member

Changing a Culture to Focus on Safety "We are at the very beginning of time for the human race. It is not unreasonable that we grapple with problems. But there are tens of thousands of years in the future. Our responsibility is to do what we can, learn what we can, improve the solutions, and pass them on." -- Richard Feynman "We are at the very beginning of time for the human race. It is not unreasonable that we grapple with problems. But there are tens of thousands of years in the future. Our responsibility is to do what we can, learn what we can, improve the solutions, and pass them on." -- Richard Feynman Recognizing The least we can do is nothing at all, The best we can is to do what we can, learning along the way Attempt to improve the solutions and share our lessons learned, We want to take this opportunity to share with you some of the principles and techniques that we have found to be effective in driving culture change.

Techniques for Enhancing a Safety Culture Encouraging Voluntary Employee Reporting of Errors and Safety Concerns Ensuring a Just Culture foundation Establishing a Safety Management System Setting Clear Expectations and Focus on Shared Values Each one of these must be supported and reinforced by Senior Leadership in order to successfully drive culture change into the organization and ensure sustainability.

Voluntary Employee Reporting Ensure employees are provided an avenue for confidential reporting of errors, violations or safety concerns without fear of reprisal Aviation Safety Action Program (ASAP) is an example of an effective reporting program whose primary objective is to learn and improve safety The FAA guidance on ASAP promises no certificate enforcement action for accepted reports in exchange for information the organization may not have known otherwise Ensure employees are provided an avenue for confidential reporting of errors, violations or safety concerns without fear of reprisal Aviation Action Safety Program (ASAP) is an example of an effective reporting program whose primary objective is to learn and improve safety The regulatory guidance on ASAP promises no FAA punitive action for accepted reports (unless it involves criminal activity, intentional falsification or intentional disregard for safety) in exchange for information the organization may not have known otherwise CAUTION – to avoid a blame-free perception (get out of jail free) a strong just culture foundation needs to be set to ensure a balanced accountability

Understanding our Safety Culture (This slide will automatically transition to the next slide in 7 seconds) The first step to change is being willing to change. The next critical step is understanding where to focus our efforts to ensure effective and sustainable change. In order to do this, organizations need to be willing to take a serious look at the organizational culture as it relates to safety, compliance and how it handles errors. You are all familiar with the Safety Culture paradigm. All organizations have a Culture related to Safety, where we end up on this scale can vary greatly across organizations, and often even within organizations. We can all agree that the most optimum state of a safety culture that is interested in learning is as close to the right on this scale as possible. But we have to beware of the varying perceptions of a “just culture”. What type of Safety Culture do we have? Secretive Just Reporting Blame

Understanding our Safety Culture System of accountability that best supports a safety culture There is also a separate spectrum as it relates to justice, of which both extremes can negatively impact a safety culture. Both sides of the spectrum will stifle reporting and create unrealistic expectations of safety responsibilities and accountabilities. A true “just” culture lies in between where there is a balanced system of accountability which best supports a safety culture. Just Culture can be defined as a safety-supportive system of shared accountability where organizations are accountable for the system design and supporting the safe choices of its employees and employees are responsible for the quality of their choices. Just Culture is not blame-free, but not overly punitive. There must be a balance in the justice system so that everyone understands acceptable and unacceptable behavior and their individual accountabilities. What is a “Just” Culture? Reporting Blame-Free Culture Punitive Culture

Facets of a Just Culture Managing System Design Anticipating and Managing Human Errors Anticipating and Managing Organizational Drift (At Risk Behavior) Setting Clear Expectations and Managing the Occasional Reckless Act Individual Accountability System Design Managing System Design – adequate policies, processes, procedures, training, expectations, resources, tools, equipment, facilities, etc. Anticipating and Managing Human Errors – ERRORS are PREDICTABLE - inadvertent actions; inadvertently doing other than what should have been done; a slip, lapse, or mistake. Anticipating and Managing Organizational Drift (At Risk Behavior) – DRIFT is PREDICTABLE - behavioral choices that increases risk where risk is not recognized, or is mistakenly believed to be justified Setting Clear Expectations and Managing the Occasional Reckless Act – RECKLESS BEHAVIOR CANNOT BE TOLERATED - a behavioral choice to consciously disregard a substantial and unjustifiable risk Organizational Values

Just Culture foundation Within ASAP Just Culture training and tools (algorithm) in ASAP provide: A common methodology A common focus Alignment of the ASAP committee Defined rejection criteria Just Culture training and tools (algorithm) in ASAP provides: A common methodology of approaching errors and violations as opportunities to improve system performance and enhance safety A common focus on comprehensive fixes to address both system design deficiencies and behavioral choices Alignment of the ASAP committee in their focus and objectives to the point that it became difficult for the University team to distinguish the voting parties to the program Defined rejection criteria to the clearly defined “reckless” behavior as opposed to the previously undefined “intentional disregard for safety” However, a just culture cannot only live within the confines of the reporting program.

Just Culture Foundation Within the Organization Just Culture training and tools embedded into the organization (policy): Maintain and enhance a positive safety culture Recognize that all humans are fallible and susceptible to drift Requires an organizational commitment The benefits of a “Just Policy”: Increased workforce trust Improved quality data collected Enhanced organizational risk picture Ability to share valuable lessons learned Just Policy is the organizations documented commitment to: - Maintain and enhance a positive safety culture Recognize that all humans are fallible and susceptible to drift Requires an organizational commitment to: Share accountability in risk management Consider error/event investigations as an opportunity to learn and the most effective means to ensure safety and compliance across the organization Take appropriate corrective action when reckless behaviors are identified The benefits of a “Just Policy”: -Increased workforce trust in the error investigation process -Increased quality data collected during the investigation -Enhanced organizational risk picture and ability to focus resources and safety initiatives effectively -Ability to share valuable lessons learned from errors/events with the workforce

Safety Management System With the requirement for a Safety Management System looming domestically, and already implemented internationally, it is critical that organizations do more than “check the box” as they establish an SMS. An effective SMS can act as a driver for culture change. In an SMS, risk management is driven by the operating departments – not by the Safety organization. Ensuring a just culture foundation will only enhance a Safety Management System. Through Safety Policy and Safety Promotion – Maintenance organizations will be responsible for ensuring the organizational safety policies are understood at all levels of the organization - that all employees (management and frontline) understand acceptable and unacceptable behaviors and that safety lessons learned are shared at levels of the organization. Through Safety Risk Management - Maintenance organizations will be required to ensure frontline leaders focus on safety and monitor and manage risks on a daily basis (which should drive safety and compliance to an equal level with production) and that employees understand their critical role in reporting errors or concerns. When employees feel safe to do this, our understanding and ability to manage risk is greatly expanded. Through Safety Assurance - Maintenance organizations will collect data through audits, investigations and employee reports to understand and manage risk in the operation. When operating in a just culture, employees will be more willing to act normally when being observed, participate freely in error/event investigations, etc. because it is clearly understood that the primary objective of an SMS (in a just culture) is to LEARN and IMPROVE.

Setting Clear (Values-Based) Expectations The most effective way to drive a culture change that is reflected in individual attitudes and behaviors is to focus your efforts on the foundation – organizational values and expectations. Think of a “School-Zone” in which the shared value is the preservation of life and the expectations are clear. In a school zone, the system is designed to support desired behaviors and discourage unacceptable behaviors. An organization will know when it has effectively changed its culture, when its individual members are holding themselves, and each other, accountable. The most effective way to drive a culture change that is reflected in individual attitudes and behaviors is to focus your efforts on the foundation – organizational values and expectations. Think of a “School-Zone” in which the shared value is the preservation of life and the expectations are clear. In a school zone, the system is designed to support desired behaviors and discourage unacceptable behaviors. An organization will know when it has effectively changed its culture, when its individual members are holding themselves, and each other, accountable.

Conclusion So, in conclusion, at American Airlines, these are some of the tested techniques we believe can be applied to truly enhance organizational safety. We believe that, by applying these techniques, we have driven our way into the foundation of our safety culture to make the most significant impact. We are changing our safety culture, by re-focusing the organization to a set of shared organizational values related to safety through efforts such as Critical Behaviors. We did this so that we can be assured that spur of the moment operational decisions that are made (at all levels of the organization) are in alignment with our organizational values – Safety, Quality and Compliance, Customer Delivery-Focus. We are changing our safety culture, by focusing on risk-based safety strategies, such as the Safety Management System, to investigate, analyze and truly understand behaviors in context with their system to drive comprehensive system improvements. We are changing our safety culture, by ensuring we have established a “true” just culture that will build trust and stabilize the safety climate of the organization, even in times of distress. We are changing our safety culture, by placing a strong value on voluntary, non-punitive employee reporting because our employees are the eyes and ears of risk in the operation. All of these efforts, together, drive the desired behaviors from employees at all levels in the organization and ultimately promote a culture that values reporting, learning and continuous improvement. *St. Louis University, Parks College – Safety Culture Pyramid

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